Basic details

Please record here ALL names or aliases by which you have been known at any time. Please start by providing your family name and given names at time of your birth:

Name

FirstLast

Date of birth

From

To

Reason for change

Do you require extra alias space

Yes

No

Name

FirstLast

Date of birth

From

To

Reason for change

Job position you are applying for

Type

Full time

Part time

Please state the number of hours*

Please enter a value between 1 and 99.

Do you hold a full UK driving license?*

Yes

No

Do you have your own car?*

Yes

No

Do you have use of a car?*

Yes

No

Why do you want to work in Domiciliary Care?*

What skills/attributes can you bring to the role?*

Any additional information which may support your application

Employment history

Where there are any gaps in employment, please give enough detail in your explanation of the circumstances to enable us to make checks if we need to. Please be sure to highlight any experience you consider to be relevant to the present application including any previous work involving caring for people, whether paid or not. Include the name and address of any present employer and the names and addresses of any previous employers together with details of any business.

If any of your previous duties involved working with children or vulnerable adults, you should give the full reasons for leaving and explain how this could be verified.

Occupation including job title

Date from

Date to

Name of employer

employer contact number

Reason for leaving

Occupation including job title

Date from

Date to

Name of employer

employer contact number

Reason for leaving

Professional or Technical Qualifications

Qualifications Gained

Awarding Body

Date of Award

Qualifications Gained

Awarding Body

Date of Award

Qualifications Gained

Awarding Body

Date of Award

Extra needed

yes

Qualifications Gained

Awarding Body

Date of Award

Qualifications Gained

Awarding Body

Date of Award

Details of membership or registration with professional - or other relevant organisations or bodies.

Organisation or professional body

Date admitted/registered

Expiry date

Type or level of Membership/Registration

Organisation or professional body

Date admitted/registered

Expiry date

Type or level of Membership/Registration

Organisation or professional body

Date admitted/registered

Expiry date

Type or level of Membership/Registration

REFEREES

Please supply the names and addresses of three individuals from whom we may take up references.
You must give the name of your current or most recent employer as the first reference. Neither of these referees may be a relative. These referees must be able to provide comment on your professional skills and competence relevant to this agency.
At least one of these referees must have employed you for at least 3 months (if it is impracticable to obtain such a reference, please explain why).

Name

Address

Contact number

Name

Address

Contact number

Name

Address

Contact number

Rehabilitation of Offenders Act 1974

Because of the nature of the work for which you are applying, this work is exempt from the provisions of section 4.2 of the Rehabilitation of Offenders Act 1974 (Exemption Order 1975). Applicants are therefore, not entitled to withhold information about convictions which for other purposes are ‘spent’ under the provisions of the Act and in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in relation to the application for positions in which the Order applies, and should be entered at the end of any particulars you give in support of your application.

You are invited below to declare any past criminal convictions and cautions regardless of how long ago they occurred. If you do not have any past convictions please state NIL

Declaration I certify that the information given in this application is to the best of my knowledge and belief complete and correct. I agree to comply with the requirements specified. I am aware that if it is discovered that I have withheld, omitted or misrepresented any facts in this application, any Application granted would be liable to cancellation and I may be liable to prosecution.

I agree to comply with the Regulations which apply and the relevant National Minimum Standards.

Signature

Date

Medical History

Do you now, or have you ever, suffered from or received treatment for the following? If your answer to any of these questions is YES please give details in the space